Punjab

Fatehgarh Sahib

RBT/CC/316/2018

Mrs. Santosh Sharma - Complainant(s)

Versus

MD India Health Insurance PPA Pvt. Ltd. - Opp.Party(s)

Vineet Kumar Chopra

12 Dec 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHGARH SAHIB.

                                                              RBT. No.316/2018    

                                                             Complaint No. 316 of 2018                                                                                 

                                                            Date of Institution:.16.3.2018                                                                          

                                                          Date of Decision: 12.12.2022

 

Mrs. Santosh Sharma aged 64 years w/o Sh.Joginder Pal Bhardwaj R/o H. No.1212, Sector 7, Panchkula.

                                                                                                                     …………....Complainant

                                                Versus

1.  MD India Health Insurance PPA Pvt. Ltd. Through Project office Adviser, Max Pro Info Park, D-38, First floor, Industrial Area, Phase 1 Mohali, Punjab-160056.
2. Head office, S. no.46/1, E-space, A-2 Building, Fourth Floor, Pune Nagar Road, Vdgaonsheri, Pune-411014
3. Oriental Insurance Company , Chandigarh through Branch Manager
4. Fortis Hospital, Mohali.

                                                                              ..………....... Opposite Parties

 

Complaint under Section 12 of Consumer Protection Act 1986(Old)

Quorum

Sh. Pushvinder Singh, President

Ms. Shivani Bhargava, Member

Sh. Manjeet Singh Bhinder, Member

Present: Shri Kant Rattan, counsel for complainant.

     Sh.Vishal Ahuja, counsel for OPs no.1 to 3.

     Sh.Munish Kapila, counsel for OP no.4

     

Order By

MS.SHIVANI  BHARGAVA, MEMBER

 

 The present complaint has been filed by the complainant  against the OPs (opposite parties),  Under Section 12 of Consumer Protection Act-1986(old) alleging deficiency in service  by repudiating her mediclaim on the ground that  AL closed as claim documents not received. She has prayed for giving directions to the OPs no.1 to3 to pay  the reimbursement of Rs.3,00,000/ out of Rs.4,22,866 (Rs.4,18,679 + Rs.4187 (TCS) ) as medical expenses incurred on her Bilateral total knee replacement surgery  in Fortis Hospital , Mohali along with interest @ 12% P.A w.e.f 19.9.2016 i.e date of payment made to the Fortis Hospital  i.e OP no.4 and to pay compensation of Rs.25,000/- towards deficiency in service, mental Physical harassment and Rs.20,000/- as litigation expenses to the complainant .

2.  The brief facts of the complaint are that complainant  is a pensioner of Punjab Government . She was covered under the Punjab Govt. employees & Pensioner health  Insurance  Scheme (PGEPHIS) for period  w.e.f 1.1.2016 to 31.12.2016. As per the terms of  PGEPHIS, every  beneficiary of this scheme was entitled for cashless treatment up to Rs. 3 Lakh in the empanelled hospitals.  The said cashless scheme was being implemented through  oriental Insurance Co. & their  TPA.  Liability to pay  premium was on the part of the state Govt.  Complainant had been issued ID Card no.MDI5-09815653354 under this PGEPHIS. Complainant suffered from  knee problem.   She was  advised for bilateral knee replacement by the doctors .  Before her admission, she got the  form of TPA- MD India  Health Insurance PPA Pvt. Ltd. ( OP 1)  submitted through  Fortis Hospital, Mohali (OP4) showing an estimated  bill of Rs.4,30,000/- which was duly signed by  Dr. Harsimran  Singh  along with diagnose  of knee replacement for approval.  The Mediclaim was to be payable by OP no.3 assisted by OP no.1.
3.   Complainant alleged that  request was approved for Rs.3,00,000/- by MD India Health Insurance PPA Pvt. Ltd (OP1) vide UHID 637298. Later on  approved amount of Rs.3,00,000/- was reduced to Rs.1,50,000/- by OP1. But on  the day of surgery i.e on 13.9.2016, she was told by OP4 i.e hospital authorities that her claim was rejected . She  was shocked  to know about the  refusal  from Insurance Company  without any reason. The  expenses incurred in the hospital  were paid  by the complainant under compulsion otherwise she had to postpone her surgery. On 10.3.2017, claim amount was being  shown as repudiated for want of documents.  Its mentioned there AL closed  as claim documents not received.  Complainant  sent E-mail  to OP no.1 regarding  claim  but no satisfactory reply  was received. Hence this complaint.
4. Notice of the complaint was given to the OPs no.1 to 4 through registered Post, OPs appeared  through their Counsels and filed  their written version.
5.  The OPs 1,2 & 3, jointly filed written version ,raised legal  objections, that the complainant is not a consumer  under  definition of the  Act. There is no insurance contract between the beneficiary  and Insurance Company. There is no point of contractual liability. There is no consideration taken from the complainant by the  Insurance  Company. Punjab Govt. had sponsored the  scheme to its employees & Pensioners and no insurance consideration is deducted from their salaries. Complainant should first approach the District Disputes Resolution and Grievance redressal mechanism as mentioned in the notification . So this commission  has no  jurisdiction to decide the  complaint. It is  denied that at no point  of  time Rs.3,00,000/- was approved and then reduced to Rs.1,50,000/-. An amount of Rs.1,50,000/- was sanctioned for cashless treatment initially against request received on 19.8.2016 . As per rules & regulations, the  empanelled Hospital/Nursing home shall be reimbursed the cost of treatment as per PGEPHIS  package Rates with hospitals. The Insurance company shall  settle the claim of the Hospitals/Nursing Homes within 15 days of receipt of the complete bills along with the discharge  summary of the  patient .  Hospital authorities  failed to submit final bill and discharge summary  with in time for the final approval & as such authorization was closed. Hospital  authorities  i.e OP no.4 did not  submit claim  folder till 10.3.2017. Hospital  is bound to submit claim folder to TPA within 15 days from the date of  discharge of  patient . So the  complainant’ claim  was not  repudiated  but the case was closed due to non submission of documents. ( AL closed as claim  documents not received).  

OP no.4 i.e Hospital Authorities alsofiled their replyand statedthat grievance of the complainant is against OPs no.1 to 3 not against OP no.4Complainant has not claimed any relief against OP no.4 . So name of OP no.4 should be deleted from the array of parties.

6.                 The complainant in support of her complaint tendered in evidence her  affidavit Ex.CW1/1 along with documents i.e  copy of  Insurance scheme as Ex.C1, copy of e-card of complainant  showing period of Insurance as Ex.C2, Approval form of 3 Lakh as Ex.C3, copy of claim repudiation  for want of documents as Ex.C4,  receipts and copy of bills of hospital of  Rs4,18,679 + Rs.4187 (TCS) as Ex.C5, Discharge slip as Ex.C6, copy of E-mail sent to OP for reimbursement of claim  as Ex.C7, acknowledgement of
   E-mail by M.D India Health as Ex.C8, copy of E-Mail sent by MD India  Devika Kohli as Ex.C9 and closed the evidence..  In rebuttal the OPs no.1 to3  jointly tendered affidavit of Charanjit Singh, Deputy Manager, OIC as Ex.OP.1/1 along with documents  i.e  copy of notification of Insurance by Govt. of Punjab ,  Department of Health  &  Family  Welfare Ex.OP1, copy of  initially  approved  amount of Rs.1,50,000/- against request received on 19.8.2016 as Ex.OP2,  OP no.4 tendered in evidence affidavit of Abhijit Singh, Zonal director, Fortis Hospital, Mohali as Ex.OP4/1 and closed the evidence
7.   We have perused the complaint  and heard the  Ld. counsels for the parties  and gone through the record on the  file.
8.  Ld. Counsels for the parties have reiterated their stand as taken  in their respective pleadings & as detailed above.
9.     There is no dispute about the fact that complainant being a  pensioner of  Punjab Government was covered  under  the Punjab Govt.  Employees and Pensioners Health scheme (PGEPHIS) w.e.f 1.1.2016 to 31.12.2016. Complainant got  her  knee replacement  treatment from  Fortis Hospital, Mohali . She got admitted in Hospital  on 12.9.2016 and discharged on 19.9.2016. On the day of  surgery  i.e on 13.9.2016, OP no.4 told the complainant  about  refusal of cashless mediclaim by OP no.1. She had  to arrange money immediately for her surgery. Fortis hospital raised a bill of Rs.4,22,866/- and the amount was paid by the complainant.
10.         OP argued that complainant is not  consumer  Under this act. It is admitted fact by the parties that Punjab Governement launched a scheme  for the  cashless medical treatment for their employees, Pensioners namely PGEPHIS and made a contract  with OPs no.1 to3.    The premium was paid by  the state Government.  Being pensioner of Punjab  Government complainant  was beneficiary  under this  scheme.    The Ops argued that this  commission has no jurisdiction to entertain the complaint .  It is settled Principle of Law that the remedy  under Consumer Protection Act is an  additional remedy  other than available remedies. Under Section 100 Consumer Protection 2019 , Provisions of the Act shall be in addition to  and not in  derogation of the  Provisions of any other law for the time being inforce.  So this commission  can  entertain and decide the complaint.

OPs no.1 to 3 had initially given their approval for Rs.1,50,000/- againstrequest raised on 19.8.2016 (Ex.OP2) as admitted by OPs no.1 to 3 in their reply. OPs no.1 to 3 deniedthat they gave approval for Rs.3,00,000/-and then reduced to Rs.1,50,000/- . On 10.3.2017 OPs no.1 to 3 closed the claim case by giving reason, AL-closed asclaim documents not received.Complainant ‘s son sent an E-mailregarding this to OP no.1 but did not get any satisfactory reply.

11.                  From  the perusal of the record on file, we find  that  complainant    had lodged  her claim with  oriental Insurance Company being Pb. Govt. Pensioner. The cashless  mediclaim  is to be reimbursed by OIC i.e OP no.3  assisted by OP no.1 .  It is admitted by OPs no.1to 3 themselves that Hospital authorities did not  send them claim  documents in time and as such  authorization  was closed .  Denial of claim by OPs no.1 to 3  is not sustainable.  As per  circular no. IRDA/HLTH/MISC/CIR/216/09/2011 issued by Insurance  Regulatory & Development authority (IRDA), a  genuine claim can not be   outrightly  rejected on the ground of delay. The Insurer is  required to enquire from the claimant as to what was the  reason for the delay in submission of the claim.      Pensioners / Employees can not suffer if Insurance  Company has  refused to reimburse the claim on the ground that  claim  documents   not submitted within time.  It is also necessary to mention that  it would not be fair &  reasonable to reject  genuine claim which had already been verified.  In cashless facility, it is hospital’s duty  to  forward claim documents. Rejection of claim  purely on technical grounds  will  result in Policy holder’ loosing  confidence in Insurance  Companies giving rise to excessive litigation.  Insurance  companies should not  repudiate the claims  unless they are convinced  that they would  not  have been  admissible  even if  reported with in specific time frame. OP no.3  can not escape from its statutory  liability. OPs no. 1 to 3 are  deficient in providing  services to the complainant.
12.        There is no averment against OP no.4 nor any claim or relief has been claimed by the complainant. There is no allegation that appropriate treatment was not  rendered to the complainant by OP no.4. OP no.4  is Proforma OP.    
13.           In view of our  above discussion, the  present complaint is partly allowed.  The claim is to be  payable by insurer i.e OP no.3  not  by claim processing agency  i.e OPs no.1 and 2.  The liability of reimbursing the incurred medical  expenses remains of the insurer and not of the agent,  who is just to process the claim at the asking of the  insurer. OP no.4 is directed to provide all the documents regarding claim of  complainant  to OPs no.1  to 3 with in 10 days from the receipt of this order.  OP no.3 i.e Oriental Insurance Company is directed to reimburse the amount  paid by the complainant to  Fortis Hospital , Mohali for her treatment as per the bills produced  the complainant  subject to the terms and conditions of policy. The Op n o.3 is also directed to pay a sum of Rs.20,000/-  to the complainant as  compensation  for mental and physical  harassment  and Rs.10,000/- as litigation expenses.  The compliance of this order be made by the OP no.3 within a period 45 days from the date of receipt of certified copy of this order. Thereafter it shall be liable for  an interest @ 6% P.A on the amount from the date of filing complaint, failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within a specific period as provided by the statute due to rush of work and large pendency. Copy of this order be sent to the complainant and the OPs as per rules. File be consigned to record room.

 

Announced 12 December 2022

                                                           

                                                                      (Pushvinder Singh)

                                                                              President

                                                                    

    

                                                                                   (Shivani Bhargava)

                                                                              Member

 

                                                                                    (Sh. Manjeet Singh Bhinder )

                                                                                                Member